maximal score in the Improvement Activities performance category alone would yield 15 points. Any combination of activities
in the four performance categories (Quality, Advancing Care
Information, Improvement Activities, and Cost) that total 15 or
more points would generate enough points to allow practices to
avoid negative payment adjustments in the 2020 payment year.

Practices that score between zero and 3.75 points in 2018 will
receive the maximum negative payment adjustment of five percent for all Medicare Part B allowable charges in 2020. Practices
that achieve scores of over 3.75 points up to just under 15 points
will receive proportional negative payment adjustments ranging from between just under an estimated negative-four percent
to a fraction of a percent. CMS estimates that between 2. 9 percent to 4. 7 percent of clinicians will receive negative payment
adjustments in 2020 based on performance in 2018.

This will change markedly in 2021 based on 2019 performance.
As defined in the MACRA legislation, all clinicians that score in
the bottom quartile below the performance threshold receive the
full negative payment adjustment. The 2019 performance threshold is projected to be in the vicinity of 78 points or higher. Based
on this assumption, all clinicians with a MIPS score of 19. 5 or lower would receive the full negative payment adjustment of seven
percent in 2021. Those that score between 19. 6 and 77.9 points
would receive negative payment adjustments on a sliding scale
from approximately - 6. 9 percent to -0.1 percent.

The MIPS positive payment adjustments are funded by the
negative payment adjustments, allowing the program to remain
budget-neutral. The maximum positive payment adjustment in
2020 (based on 2018 performance) is five percent, but only if
there are sufficient funds from negative payment adjustments
to provide adequate funding for the positive payment adjustments at this level. Medicare estimates that approximately $118
million dollars will be redistributed from low performers to high
performers in the 2020 payment year.

Given the relatively low performance threshold of 15 points set by
CMS in 2018, it is highly unlikely that there will be adequate funds
to fully compensate the high-performing practices. The actual payment adjustment amounts based on 2018 performance will not be
determined until late 2019 and the information shared in this article is based upon CMS estimates provided in the 2018 QPP Final
Rule. CMS estimates that a MIPS Score of 100 points may only result
in positive payment adjustments, excluding the additional positive
payment adjustment described below, of one to two percent.

However, Congress authorized an independent fund of $500
million to allow for additional positive payment adjustments
for exceptional performance. These funds are only available in
the first six years of the MIPS program. CMS was also given the
authority to determine the performance threshold for the additional positive payment adjustment in the 2017 and 2018 performance year and it was established in both years at 70 points.
Practices that receive a MIPS score of 70 points will have an additional adjustment of +0.5 percent added to their “standard”
payment adjustment earned by the practice. From here it will
increase proportional to the practice’s MIPS score on a sliding
scale, reaching a maximum of 10 percent for MIPS scores of 100
points, assuming there are adequate funds.

CMS estimates that approximately 74 percent of clinicians will
achieve MIPS scores of 70 or higher, making them eligible for the
additional positive payment adjustment. This will dilute these funds
considerably. For example, practices that achieve a MIPS score of 85
points in 2018 may only receive an additional positive payment adjustment of up to one percentage point. This would be added to their
“standard” positive payment adjustment, which will also be markedly diluted in the 2020 payment year. Scores of 100 MIPS points could
potentially result in practices seeing up to an additional two percent
or higher payment adjustment during the 2020 payment year. As
stated previously, these numbers are based on estimates and the actual adjustments may be significantly higher or lower depending on
the number of clinicians that score below 15 points and the number
that achieve the 70-point additional payment adjustment threshold.
Please see Figures 1 and 2 on page 23 for a graphical representation
of hypothetical payment adjustments based on MIPS scores in 2018
and 2019.

In future years, starting in 2021 (based on 2019 performance) there
will be a significantly greater amount of funds available for positive
payment adjustments as nearly 50 percent of all MIPS participants
will receive negative payment adjustments. High MIPS scores in
2019 are projected to provide significantly higher positive payment
adjustments in 2021 than they did in 2020 based on 2018 performance.

Additional funds from the $500 million additional positive payment adjustment funds should also be available to high performers in the 2021 payment year. CMS is required, starting in the 2019
performance year, to establish the performance threshold for the
additional positive payment adjustment at 25 percent of the difference between the MIPS payment threshold and 100 points. For
example, if the MIPS payment threshold is 78 points in 2019, the additional positive payment adjustment would have a threshold of 83.5
points—substantially higher than the value of 70 points in 2018.

Available funds for high-performing practices may increase
further during the 2020 performance year when payment adjustments, excluding the additional positive payment adjustment for exceptional performance, will reach their maximum
range of negative-nine percent to positive-nine percent.

If there are adequate funds from negative adjustments, the
positive adjustment can be multiplied by a factor of up to three
to maintain budget neutrality. Although this is not likely to occur, a practice with a MIPS score of 100 points in 2020 could receive payment adjustments as high as 37 percent in 2022, based
on the maximum “standard” payment adjustment of positive-nine percent multiplied by a factor of three, and the 10 percent
additional positive payment adjustment. Figure 3 on page 24
provides a graphical comparison of potential adjustments with
and without the 3X multiplier.

MIPS Performance Category Weightings

Two of the MIPS performance category weightings for the 2018
performance year have been modified as compared to 2017.

The Cost performance category will be weighted at 10 percent
of the final MIPS score. It was weighted at zero percent in the
2017 performance period, and will be weighted at 30 percent in
the 2019 performance period. For the 2018 performance period,